International Journal of Surgical Oncology http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Neoadjuvant Therapy in Differentiated Thyroid Cancer Thu, 22 Sep 2016 06:13:48 +0000 http://www.hindawi.com/journals/ijso/2016/3743420/ Objectives. Invasion of differentiated thyroid cancer (DTC) into surrounding structures can lead to morbid procedures such as laryngectomy and tracheal resection. In these patients, there is a potential role for neoadjuvant therapy. Methods. We identified three studies involving the treatment of DTC with neoadjuvant chemotherapy: two from Slovenia and one from Japan. Results. These studies demonstrate that in selected situations, neoadjuvant chemotherapy can have a good response and allow for a more complete surgical resection, the treatment of DTC. Additionally, the SELECT trial shows that the targeted therapy lenvatinib is effective in the treatment of DTC and could be useful as neoadjuvant therapy for this disease due to its short time to response. Pazopanib has also demonstrated promise in phase II data. Conclusions. Thus, chemotherapy in the neoadjuvant setting could possibly be useful for managing advanced DTC. Additionally, some of the new tyrosine kinase inhibitors (TKIs) hold promise for use in the neoadjuvant setting in DTC. Rajan P. Dang, Daniel McFarland, Valerie H. Le, Nadia Camille, Brett A. Miles, Marita S. Teng, Eric M. Genden, and Krzysztof J. Misiukiewicz Copyright © 2016 Rajan P. Dang et al. All rights reserved. Liposarcoma of the Spermatic Cord: Impact of Final Surgical Intervention—An Institutional Experience Thu, 14 Apr 2016 06:23:50 +0000 http://www.hindawi.com/journals/ijso/2016/4785394/ Background. Paratesticular liposarcomas are almost always mistakenly diagnosed as inguinal hernias subsequently followed by inadequate operation. Methods. 14 consecutive patients with paratesticular liposarcoma were retrospectively reviewed. Preoperative management was evaluated. Disease-free and overall survival were determined. Results. In 11 patients primary and in 3 patients recurrent liposarcoma of the spermatic cord were diagnosed. Regarding primary treatment in primary surgical intervention resection was radical (R0) in 7 of 14 (50%) patients, marginal (R1) in 6 (43%) patients, and incomplete with macroscopic residual tumour (R2) in 1 (7%) patient. Primary treatment secondary surgical intervention was performed in 4 patients: resection was radical (R0) in 3 (75%) patients and marginal (R1) in 1 (25%) patient. Regarding secondary treatment in recurrent disease resection was marginal (R1) in 3 patients (100%). Final histologic margins were negative in 10 patients with primary disease (71%) and positive in 4 patients with subsequent recurrent disease. After radical resection disease-free survival rates at 3 years were 100%. Overall survival at 4.5 years (54 (18–180) months) was 64%. Conclusion. An incomplete first surgical step increases the number of positive margins leading to local recurrences and adverse prognoses. Aggressive surgery should be attempted to attain 3-dimensional negative margins. R. Bachmann, J. Rolinger, P. Girotti, H. G. Kopp, K. Heissner, B. Amend, A. Königsrainer, and R. Ladurner Copyright © 2016 R. Bachmann et al. All rights reserved. Current Practice of Therapeutic Mammaplasty: A Survey of Oncoplastic Breast Surgeons in England Wed, 23 Mar 2016 09:55:36 +0000 http://www.hindawi.com/journals/ijso/2016/1947876/ Introduction. Therapeutic mammaplasty (TM) is a useful technique in the armamentarium of the oncoplastic breast surgeon (OBS). There is limited guidance on patient selection, technique, coding, and management of involved margins. The practices of OBS in England remain unknown. Methods. Questionnaires were sent to all OBS involved with the Training Interface Group. We assessed the number of TM cases performed per surgeon, criteria for patient selection, pedicle preference, contralateral symmetrisation, use of routine preoperative MRI, management of involved margins, and clinical coding. Results. We had an overall response rate of 43%. The most common skin resection technique utilised was wise pattern followed by vertical scar. Superior-medial pedicle was preferred by the majority of surgeons (62%) followed by inferior pedicle (34%). Twenty percent of surgeons would always proceed to a mastectomy following an involved margin, whereas the majority would offer reexcision based on several parameters. The main absolute contraindication to TM was tumour to breast ratio >50%. One in five surgeons would not perform TM in smokers and patients with multifocal disease. Discussion. There is a wide variation in the practice of TM amongst OBS. Further research and guidance would be useful to standardise practice, particularly management of involved margins and coding for optimal reimbursement. Shweta Aggarwal, Sekhar Marla, Donald Nyanhongo, Sita Kotecha, and Narendra Nath Basu Copyright © 2016 Shweta Aggarwal et al. All rights reserved. A Structured Assessment to Decrease the Amount of Inconclusive Endometrial Biopsies in Women with Postmenopausal Bleeding Sun, 13 Mar 2016 12:06:12 +0000 http://www.hindawi.com/journals/ijso/2016/3039261/ Objective. To determine whether structured assessment of outpatient endometrial biopsies decreases the number of inconclusive samples. Design. Retrospective cohort study. Setting. Single hospital pathology laboratory. Population. Endometrial biopsy samples of 66 women with postmenopausal bleeding, collected during the usual diagnostic work-up and assessed as insufficient for a reliable histological diagnosis. Methods. Endometrial biopsy samples were requested from the pathology laboratories. The retrieved samples were systematically reassessed by a single pathologist specialized in gynecology. Main Outcome Measure. Disagreement between initial assessment and conclusion after structured reassessment. Results. We retrieved 36 of 66 endometrial biopsy samples from six different pathology laboratories. Structured reassessment of the retrieved samples by a single pathologist specialized in gynecology did not change the conclusion in 35 of the 36 samples. The remaining sample contained a large amount of endometrial tissue and the diagnosis at reassessment was endometrial hyperplasia without atypia. All other samples contained insufficient material for a reliable diagnosis. Conclusion. A structured reassessment of endometrial biopsies samples, which were classified as inconclusive due to insufficient material, did not change the conclusion. Although it might be helpful for pathologists to have diagnostic criteria for adequacy and/or inadequacy of an endometrial biopsy sample, the gain in efficiency is likely to be small. M. C. Breijer, N. C. M. Visser, N. van Hanegem, A. A. van der Wurff, B. C. Opmeer, H. C. van Doorn, B. W. J. Mol, J. M. A. Pijnenborg, and A. Timmermans Copyright © 2016 M. C. Breijer et al. All rights reserved. Prognostic Relevance of the Peritoneal Surface Disease Severity Score Compared to the Peritoneal Cancer Index for Colorectal Peritoneal Carcinomatosis Tue, 23 Feb 2016 09:25:17 +0000 http://www.hindawi.com/journals/ijso/2016/2495131/ Background. Peritoneal Carcinomatosis Index (PCI) is a widely established scoring system that describes disease burden in isolated colorectal peritoneal carcinomatosis (CPC). Its significance may be diminished with complete cytoreduction. We explore the utility of the recently described Peritoneal Surface Disease Severity Score (PSDSS) and compare its prognostic value against PCI. Methods. The endpoints were overall survival (OS), progression-free survival (PFS), and survival less than 18 months (18 MS). Results. Fifty patients underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for CPC from 2003 to 2014, with 98% achieving complete cytoreduction. Median OS was 28.8 months (95% CI, 18.0–39.1); median PFS was 9.4 months (95% CI, 7.7–13.9). Univariate analysis showed that higher PCI was significantly associated with poorer OS (HR 1.11; 95% CI, 1.03–1.20) and PFS (HR 1.09; 95% CI, 1.03–1.14). Conversely, PSDSS was not associated with either endpoint. Multivariate analysis showed that PCI, but not PSDSS, was predictive of OS and PFS. PCI was also able to discriminate survival outcomes better than PSDSS for both OS and PFS. There was no association between 18 MS and either score. Conclusion. PCI is superior to PSDSS in predicting OS and PFS and remains the prognostic score of choice in CPC patients undergoing CRS/HIPEC. Jia Lin Ng, Whee Sze Ong, Claramae Shulyn Chia, Grace Hwei Ching Tan, Khee-Chee Soo, and Melissa Ching Ching Teo Copyright © 2016 Jia Lin Ng et al. All rights reserved. A Review of the Literature on Extrarenal Retroperitoneal Angiomyolipoma Wed, 17 Feb 2016 09:50:00 +0000 http://www.hindawi.com/journals/ijso/2016/6347136/ Background. Extrarenal retroperitoneal angiomyolipomas are rare. Aim. To review the literature. Results. Angiomyolipomas, previously classified as hamartomas, are now classified as benign tumours. Thirty cases of primary retroperitoneal angiomyolipomas have been reported. Diagnosis of the disease upon is based radiological and pathological findings of triphasic features of (a) fat and (b) blood vessels and myoid tissue. Immunohistochemistry tends to be positive for HMB45, MART1, HHF35, calponin, NKI-C3, and CD117. The lesion is common in women. Treatment options have included the following: (a) radical surgical excision of the lesion with renal sparing surgery or radical nephrectomy in cases where malignant tumours could not be excluded and (b) selective embolization of the lesion alone or prior to surgical excision. One case of retroperitoneal angiomyolipoma was reported in a patient 15 years after undergoing radical nephrectomy for angiomyolipoma of kidney and two cases of distant metastases of angiomyolipoma have been reported following radical resection of the tumour. Conclusions. With the report of two cases of metastases ensuing surgical resection of the primary lesions there is need for academic pathologists to debate and review angiomyolipomas to decide whether to reclassify angiomyolipomas as slow-growing malignant tumours or whether the reported cases of metastases were de novo tumours or metastatic lesions. Anthony Kodzo-Grey Venyo Copyright © 2016 Anthony Kodzo-Grey Venyo. All rights reserved. Neoadjuvant Chemotherapy in Locally Advanced and Borderline Resectable Nonsquamous Sinonasal Tumors (Esthesioneuroblastoma and Sinonasal Tumor with Neuroendocrine Differentiation) Wed, 03 Feb 2016 10:58:30 +0000 http://www.hindawi.com/journals/ijso/2016/6923730/ Introduction. Sinonasal tumors are chemotherapy responsive which frequently present in advanced stages making NACT a promising option for improving resection and local control in borderline resectable and locally advanced tumours. Here we reviewed the results of 25 such cases treated with NACT. Materials and Methods. Sinonasal tumor patients treated with NACT were selected for this analysis. These patients received NACT with platinum and etoposide for 2 cycles. Patients who responded and were amenable for gross total resection underwent surgical resection and adjuvant CTRT. Those who responded but were not amenable for resection received radical CTRT. Patients who progressed on NACT received either radical CTRT or palliative radiotherapy. Results. The median age of the cohort was 42 years (IQR 37–47 years). Grades 3-4 toxicity with NACT were seen in 19 patients (76%). The response rate to NACT was 80%. Post-NACT surgery was done in 12 (48%) patients and radical chemoradiation in 9 (36%) patients. The 2-year progression free survival and overall survival were 75% and 78.5%, respectively. Conclusion. NACT in sinonasal tumours has a response rate of 80%. The protocol of NACT followed by local treatment is associated with improvement in outcomes as compared to our historical cohort. Vijay M. Patil, Amit Joshi, Vanita Noronha, Vibhor Sharma, Saurabh Zanwar, Sachin Dhumal, Shubhada Kane, Prathamesh Pai, Anil D’Cruz, Pankaj Chaturvedi, Atanu Bhattacharjee, and Kumar Prabhash Copyright © 2016 Vijay M. Patil et al. All rights reserved. Influence of Individual Surgeon Volume on Oncological Outcome of Colorectal Cancer Surgery Thu, 03 Sep 2015 07:59:54 +0000 http://www.hindawi.com/journals/ijso/2015/464570/ Background. Surgery performed by a high-volume surgeon improves short-term outcomes. However, not much is known about long-term effects. Therefore we performed the current study to evaluate the impact of high-volume colorectal surgeons on survival. Methods. We conducted a retrospective analysis of our prospectively collected colorectal cancer database between 2004 and 2011. Patients were divided into two groups: operated on by a high-volume surgeon (>25 cases/year) or by a low-volume surgeon (<25 cases/year). Perioperative data were collected as well as follow-up, recurrence rates, and survival data. Results. 774 patients underwent resection for colorectal malignancies. Thirteen low-volume surgeons operated on 453 patients and 4 high-volume surgeons operated on 321 patients. Groups showed an equal distribution for preoperative characteristics, except a higher ASA-classification in the low-volume group. A high-volume surgeon proved to be an independent prognostic factor for disease-free survival in the multivariate analysis . Although overall survival did show a significant difference in the univariate analysis it failed to reach statistical significance in the multivariate analysis . Conclusions. In our study, a higher number of colorectal cases performed per surgeon were associated with longer disease-free survival. Implementing high-volume surgery results in improved long-term outcome following colorectal cancer. Marleen Buurma, Hidde M. Kroon, Marlies S. Reimers, and Peter A. Neijenhuis Copyright © 2015 Marleen Buurma et al. All rights reserved. A Single Centre Analysis of Clinical Characteristics and Treatment of Endocrine Pancreatic Tumours Mon, 08 Jun 2015 11:39:02 +0000 http://www.hindawi.com/journals/ijso/2015/538948/ Background. Endocrine Pancreatic Tumours (PENs) are rare and can be nonfunctioning or functioning. They carry a good prognosis overall though high grade lesions show a relatively shorter survival. The aim of the current study is to describe a single centre analysis of the clinical characteristics and surgical treatment of PENs. Patients and Methods. This is a cohort analysis of 40 patients of PENs who underwent surgery at Sir Ganga Ram Hospital, New Delhi, India, from 1995 to 2013. Patient particulars, clinical features, surgical interventions, postoperative outcome, and followup were done and reviewed. The study group was divided based on grade (G1, G2, and G3) and functionality (nonfunctioning versus functioning) for comparison. Results. PENs comprised 6.3% of all pancreatic neoplasms (40 of 634). Twenty-eight patients (70%) had nonfunctioning tumours. Eighteen PENs (45%) were carcinomas (G3), all of which were nonfunctioning. 14 (78%) of these were located in the pancreatic head and uncinate process (). The high grade (G3) lesions were significantly larger in size than the lower grade (G1 + G2) tumours (7.0 ± 3.5 cms versus 3.1 ± 1.6 cms, ). Pancreatoduodenectomy was performed in 18 (45%), distal pancreatectomy in 10 (25%), and local resection in 8 (20%) and nonresective procedures were performed in 4 patients (10%). Fourteen patients (35%) had postoperative complications. All G3 grade tumours which were resected had positive lymph nodes (100%) and 10 had angioinvasion (71%). Eight neoplasms (20%) were cystic, all being grade G3 carcinomas, while the rest were solid. The overall disease related mortality attributable to PEN was 14.3% (4 of 28) and for malignant PENs was 33.3% (4 of 12) after a mean follow-up period of 49.6 months (range: 2–137 months). Conclusion. Majority of PENs are nonfunctioning. They are more likely malignant if they are nonfunctioning and large in size, show cystic appearance, and are situated in the pancreatic head. Early surgery leads to good long term survival with acceptable postoperative morbidity. M. T. Adil, R. Nagaraja, V. Varma, N. Mehta, V. Kumaran, and S. Nundy Copyright © 2015 M. T. Adil et al. All rights reserved. Gastrectomy and D2 Lymphadenectomy for Gastric Cancer: A Meta-Analysis Comparing the Harmonic Scalpel to Conventional Techniques Thu, 14 May 2015 06:55:25 +0000 http://www.hindawi.com/journals/ijso/2015/397260/ The ultrasonic Harmonic scalpel has demonstrated clinical and surgical benefits in dissection and coagulation. To evaluate its use in gastrectomy, we conducted a systematic review and meta-analysis of randomized controlled trials comparing the Harmonic scalpel to conventional techniques in gastrectomy for patients with gastric cancer. International databases were searched without language restrictions for comparisons in open or laparoscopic gastrectomy and lymphadenectomy. The meta-analysis used a random-effects model for all outcomes; continuous variables were analyzed for mean differences and dichotomous variables were analyzed for risk ratios. Sensitivity analyses were conducted for study quality, type of conventional technique, and imputation of study results. Ten studies () met the inclusion criteria. Compared with conventional hemostatic techniques, the Harmonic scalpel demonstrated significant reductions in operating time (−27.5 min; ), intraoperative blood loss (−93.2 mL; ), and drainage volume (−138.8 mL; ). Results were numerically higher for conventional techniques for hospital length of stay, complication risk, and transfusions but did not reach statistical significance. Results remained robust to sensitivity analyses. This meta-analysis demonstrates the clear advantages of using the Harmonic scalpel compared to conventional techniques, with improvements demonstrated across several outcome measures for patients undergoing gastrectomy and lymphadenectomy. Hang Cheng, Chia-Wen Hsiao, Jeffrey W. Clymer, Michael L. Schwiers, Bryanna N. Tibensky, Leena Patel, Nicole C. Ferko, and Edward Chekan Copyright © 2015 Hang Cheng et al. All rights reserved. Now, Later of Never: Multicenter Randomized Controlled Trial Call—Is Surgery Necessary after Atypical Breast Core Biopsy Results in Mammographic Screening Settings? Tue, 21 Apr 2015 12:41:33 +0000 http://www.hindawi.com/journals/ijso/2015/192579/ Breast cancer mammographic screening leads to detection of premalignant and preinvasive lesions with an increasing frequency. Nevertheless, current epidemiologic evidence indicates that the screening reduces breast cancer specific mortality, but not overall mortality in breast cancer patients. The evidence is lacking whether aggressive eradication of DCIS (preinvasive form of breast carcinoma) by surgery and radiation is of survival benefit, as long-term breast cancer specific mortality in a cohort of patients with DCIS is already in a single digit percent range. Furthermore, it is currently not known whether the aggressive surgical eradication of atypical breast lesions which fall short of diagnosis of DCIS is of any benefit for the patients. Here we propose a model for a randomized controlled trial to generate high level evidence and solve this dilemma. Nikita Makretsov Copyright © 2015 Nikita Makretsov. All rights reserved. Mucus Containing Cystic Lesions “Mucocele” of the Appendix: The Unresolved Issues Mon, 23 Mar 2015 11:15:16 +0000 http://www.hindawi.com/journals/ijso/2015/139461/ Background. Mucocele of the appendix is a rare condition, the pathological classification and management strategy of which have not been standardized yet. Aim. To report on our management of appendiceal mucocele, highlighting the pitfalls and possible means for avoiding them. Materials and Methods. Our registries were reviewed to retrieve cases of appendiceal mucocele, encountered in the period from July 2008 to May 2013. Results. We had 9 cases, three males and sex females, with a median age of 62 years. Abdominal ultrasound (US) and computerized axial tomography scan (CT) suspected the diagnosis in only one case each. Open appendectomy was done in two cases of mucinous cystadenoma with no further surgery performed, despite the positive margin in one. Laparoscopic appendectomy was done in three cases: mucinous cystadenoma in one case which needed no further surgery, mucinous cystadenocarcinoma with pseudomyxoma peritonei in another, and low grade mucinous tumour in a third case, and all needed subsequent right hemicolectomy. Exploratory laparotomy was done in three cases: of these, synchronous right hemicolectomy was done in one case of mucinous cystadenoma/?mucinous tumour of uncertain malignant potential; in the other two cases, appendectomy only was done for mucinous hyperplasia with carcinoid tumour of the appendix in one case and mucinous cystadenoma/?mucinous tumour of uncertain malignant potential in another. The 9th case was discovered upon laparoscopy for cholecystectomy; when pseudomyxoma peritonei arising from an appendiceal mucocele was found, laparoscopic appendectomy with peritoneal biopsy was then performed instead. Histopathologic diagnostic uncertainty was present in two cases of mucinous cystadenoma where mucinous tumour of uncertain malignant potential was an alternative possibility. Perioperative colonoscopy was performed in only one case and our follow-up programme was defective, with the longest period being 180 days. Conclusion. Mucocele of the appendix should be considered in the differential diagnosis of cystic lesions in the right lower abdomen. Owing to its rarity, it continues to intrigue the surgeon as well as the radiologist and pathologist alike. For mucinous cystadenocarcinoma, right hemicolectomy is usually needed, whereas for hyperplasia and cystadenoma, appendectomy usually suffices if the resection margins are free. For mucinous tumours of uncertain malignant potential and low grade mucinous tumours as well as pseudomyxoma peritonei, the decision is not as simple. As for laparoscopic surgery, no solid proof exists with or against its safety. Although not yet standardized, perioperative colonoscopy and regular follow-up to detect early recurrences should probably be part of the management plan. Mohammad Ezzedien Rabie, Mubarak Al Shraim, Mohammad Saad Al Skaini, Saad Alqahtani, Ismail El Hakeem, Abdulla Saad Al Qahtani, Tarek Malatani, and Abduelah Hummadi Copyright © 2015 Mohammad Ezzedien Rabie et al. All rights reserved. Peritoneal Carcinomatosis: Intraoperative Parameters in Open (Coliseum) versus Closed Abdomen Hipec Sun, 15 Feb 2015 09:29:07 +0000 http://www.hindawi.com/journals/ijso/2015/610597/ Background. Peritoneal carcinomatosis (PC) is associated with a poor prognosis. Cytoreductive surgery (CRS) and HIPEC play an important role in well-selected patients with PC. The aim of the study is to present the differences in the intraoperative parameters in patients who received HIPEC in two different manners, open versus closed abdomen. Patients and Methods. The population includes 105 patients with peritoneal carcinomatosis from colorectal, gastric, and ovarian cancer, sarcoma, mesothelioma, and pseudomyxoma peritonei. Group A received HIPEC using the open technique and Group B received HIPEC with the closed technique. The main end points were morbidity, mortality, and overall hospital stay. Results. There were two postoperative deaths (3.3%) in the open group versus no deaths in the closed group. Twenty-two patients in the open group (55%) had grade III-IV complications versus 18 patients in the closed group (40%). There are more stable intraoperative conditions in the closed abdomen HIPEC in CVP, pulse rate, and systolic pressure parameters. Conclusions. Both methods are equal in the HIPEC procedures. Perhaps the closed method is the method of choice for frail patients due to more stable hemodynamic parameters. E. Halkia, A. Tsochrinis, D. T. Vassiliadou, A. Pavlakou, A. Vaxevanidou, A. Datsis, E. Efstathiou, and J. Spiliotis Copyright © 2015 E. Halkia et al. All rights reserved. Implementation of a Robotic Surgical Program in Gynaecological Oncology and Comparison with Prior Laparoscopic Series Sun, 15 Feb 2015 08:20:23 +0000 http://www.hindawi.com/journals/ijso/2015/814315/ Background. Robotic surgery in gynaecological oncology is a rapidly developing field as it offers several technical advantages over conventional laparoscopy. An audit was performed on the outcome of robotic surgery during our learning curve and compared with recent well-established laparoscopic procedure data. Method. Following acquisition of the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, USA), we prospectively analysed all cases performed over the first six months by one experienced gynaecologist who had been appropriately trained and mentored. Data on age, BMI, pathology, surgery type, blood loss, morbidity, return to theatre, hospital stay, and readmission rate were collected and compared with a consecutive series over the preceding 6 months performed laparoscopically by the same team. Results. A comparison of two consecutive series was made. The mean age was somewhat different, 55 years in the robotic versus 69 years in the laparoscopic group, but obesity was a feature of both groups with a mean of BMI 29.3 versus 28.06, respectively. This difference was not statistically significant . Three subgroups of minimal access surgical procedures were performed: total hysterectomy and bilateral salpingooophorectomy (TH + BSO), total hysterectomy and bilateral salpingooophorectomy plus bilateral pelvic lymphadenectomy (TH + BSO + BPLND), and radical hysterectomy plus bilateral pelvic lymphadenectomy (RH + BPLND). The mean time taken to perform surgery for TH + BSO was longer in the robotic group, 151.2 min compared to 126.3 min in the laparoscopic group. TH + BSO + BPLND surgical time was similar to 178.3 min in robotic group and 176.5 min in laparoscopic group. RH + BPLND surgical time was similar, 263.6 min (robotic arm) and 264.0 min (laparoscopic arm). However, the numbers in this initial analysis were small especially in the last two subgroups and do not allow for statistical analysis. The rate of complications necessitating intervention (Clavien-Dindo classification grade 2/3) was higher in the robotic arm (22.7%) compared to the laparoscopic approach (4.5%). The readmission rate was higher in the robotic group (18.2%) compared to the laparoscopic group (4.5%). The return to theatre in the robotic group was 18.2% and 4.5% in laparoscopic group. Uncomplicated robotic surgery hospital stay appeared to be shorter, 1.3 days compared to the uncomplicated laparoscopic group, 2.5 days. There was no conversion to the open procedure in either arm. Estimated blood loss in all cases was less than 100 mL in both groups. Conclusion. Robotic surgery is comparable to laparoscopic surgery in blood loss; however, the hospital stay in uncomplicated cases appears to be longer in the laparoscopic arm. Surgical robotic time is equivalent to laparoscopic in complex cases but may be longer in cases not requiring lymph node dissection. The robotic surgery team learning curve may be associated with higher rate of morbidity. Further research on the benefits to the surgeon is needed to clarify the whole picture of this versatile novel surgical approach. Natalia Povolotskaya, Robert Woolas, and Dirk Brinkmann Copyright © 2015 Natalia Povolotskaya et al. All rights reserved. Pelvic Exenteration: Experience from a Rural Cancer Center in Developing World Sun, 08 Feb 2015 13:33:11 +0000 http://www.hindawi.com/journals/ijso/2015/729658/ Background. Pelvic exenteration (PE) is a morbid procedure. Ours is a rural based cancer center limited trained surgical oncology staff. Hence, this audit was planned to evaluate morbidity and outcomes of all patients undergoing PE at our center. Methods. This is a IRB approved retrospective audit of all patients who underwent PE at our center from January 2010 to August 2013. The toxicity grades were retrospectively assigned according to the CTCAE version 4.02 criteria. Chi-square test was done to identify factors affecting grades 3–5 morbidity. Kaplan Meier survival analysis has been used for estimation of median PFS and OS. Results. 34 patients were identified, with the median age of 52 years (28–73 years). Total, anterior, posterior, and modified posterior exenterations were performed in 4 (11.8%), 5 (14.7%), 14 (41.2%), and 11 (32.4%) patients, respectively. The median time for surgery was 5.5 hours (3–8 hours). The median blood loss was 500 mL (200–4000 mL). CTCAE version 4.02 grades 3-4 toxicity was seen in nine patients (25.7%). The median estimated progression free survival was 31.76 months (25.13–38.40 months). The 2-year overall survival was 97.14%. Conclusion. PE related grades 3–5 morbidity of 25.7% and mortality of 2.9% at our resource limited center are encouraging. Sampada B. Dessai, Satheesan Balasubramanian, Vijay M. Patil, Santam Chakraborty, Atanu Bhattacharjee, and Syam Vikram Copyright © 2015 Sampada B. Dessai et al. All rights reserved. Contralateral Risk-Reducing Mastectomy: Review of Risk Factors and Risk-Reducing Strategies Tue, 27 Jan 2015 11:12:27 +0000 http://www.hindawi.com/journals/ijso/2015/901046/ Rates of contralateral risk-reducing mastectomy have increased substantially over the last decade. Surgical oncologists are often in the frontline, dealing with requests for this procedure. This paper reviews the current evidence base regarding contralateral breast cancer, assesses the various risk-reducing strategies, and evaluates the cost-effectiveness of contralateral risk-reducing mastectomy. N. N. Basu, L. Barr, G. L. Ross, and D. G. Evans Copyright © 2015 N. N. Basu et al. All rights reserved. Minimising Unnecessary Mastectomies in a Predominantly Chinese Community Mon, 26 Jan 2015 13:49:12 +0000 http://www.hindawi.com/journals/ijso/2015/684021/ Background. Recent data shows that the use of breast conservation treatment (BCT) for breast cancer may result in superior outcomes when compared with mastectomy. However, reported rates of BCT in predominantly Chinese populations are significantly lower than those reported in Western countries. Low BCT rates may now be a concern as they may translate into suboptimal outcomes. A study was undertaken to evaluate BCT rates in a cohort of predominantly Chinese women. Methods. All patients who underwent surgery on the breast at the authors’ healthcare facility between October 2008 and December 2011 were included in the study and outcomes of treatment were evaluated. Results. A total of 171 patients were analysed. Two-thirds of the patients were of Chinese ethnicity. One hundred and fifty-six (85.9%) underwent BCT. Ninety-eight of 114 Chinese women (86%) underwent BCT. There was no difference in the proportion of women undergoing BCT based on ethnicity. After a median of 49 months of follow-up, three patients (1.8%) had local recurrence and 5 patients (2.9%) suffered distant metastasis. Four patients (2.3%) have died from their disease. Conclusion. BCT rates exceeding 80% in a predominantly Chinese population are possible with acceptable local and distant control rates, thereby minimising unnecessary mastectomies. Mona P. Tan, Nadya Y. Sitoh, and Yih Y. Sitoh Copyright © 2015 Mona P. Tan et al. All rights reserved. Clear Cell Adenocarcinoma of the Urethra: Review of the Literature Tue, 20 Jan 2015 08:47:48 +0000 http://www.hindawi.com/journals/ijso/2015/790235/ Background. Clear cell adenocarcinoma of the urethra (CCAU) is extremely rare and a number of clinicians may be unfamiliar with its diagnosis and biological behaviour. Aims. To review the literature on CCAU. Methods. Various internet databases were used. Results/Literature Review. (i) CCAU occurs in adults and in women in the great majority of cases. (ii) It has a particular association with urethral diverticulum, which has been present in 56% of the patients; is indistinguishable from clear cell adenocarcinoma of the female genital tract but is not associated with endometriosis; and probably does not arise by malignant transformation of nephrogenic adenoma. (iii) It is usually, readily distinguished from nephrogenic adenoma because of greater cytological a-typicality and mitotic activity and does not stain for prostate-specific antigen or prostatic acid phosphatase. (iv) It has been treated by anterior exenteration in women and cystoprostatectomy in men and at times by radiotherapy; chemotherapy has rarely been given. (v) CCAU is aggressive with low 5-year survival rates. (vi) There is no consensus opinion of treatment options that would improve the prognosis. Conclusions. Few cases of CCAU have been reported. Urologists, gynaecologists, pathologists, and oncologists should report cases of CCAU they encounter and enter them into a multicentric trial to determine the best treatment options that would improve the prognosis. Anthony Kodzo-Grey Venyo Copyright © 2015 Anthony Kodzo-Grey Venyo. All rights reserved. Evaluating the Feasibility of Performing Window of Opportunity Trials in Breast Cancer Tue, 20 Jan 2015 07:56:06 +0000 http://www.hindawi.com/journals/ijso/2015/785793/ Background. The waiting period to surgery represents a valuable “window of opportunity” to evaluate novel therapeutic strategies. Interventional studies performed during this period require significant multidisciplinary collaboration to overcome logistical hurdles. We undertook a one-year prospective window of opportunity study to assess feasibility. Methods. Eligible newly diagnosed postmenopausal, estrogen receptor positive breast cancer patients awaiting primary surgery received anastrozole daily until surgery. Feasibility was assessed by (a) the proportion of patients who consented and (b) completed the study. Comparison of pre- and poststudy Ki67 labelling index and cleaved caspase 3 scores (CC3) was performed. Results. 22/131 (16.8%) patients were confirmed eligible and 20/22 (91%) patients completed the study. 19/20 (95%) patients agreed to undergo optional additional tissue biopsies. The mean duration of anastrozole use was 24.7 (15–44) days. There were a statistically significant decline in mean Ki67 indices of 48.8% () and a trend towards significance in the decline of CC3 () when comparing pre- with posttreatment values. Conclusion. window of opportunity trials in breast cancer are a feasible way of assessing the biologic efficacy of different therapies in the presurgical setting. The majority of eligible women were willing to participate including undergoing additional tissue biopsies. Angel Arnaout, Susan Robertson, Iryna Kuchuk, Demetrios Simos, Gregory R. Pond, Christina L. Addison, Mehrzad Namazi, and Mark Clemons Copyright © 2015 Angel Arnaout et al. All rights reserved. Clinical Characteristics and Prognosis of Incidentally Detected Lung Cancers Mon, 05 Jan 2015 08:54:30 +0000 http://www.hindawi.com/journals/ijso/2015/287604/ Objective. To evaluate clinical characteristics and outcomes in incidentally detected lung cancer and in symptomatic lung cancer. Material and Methods. We designed a retrospective study including all patients undergoing pulmonary resection with a curative intention for NSCLC. They were classified into two groups according to the presence or absence of cancer-related symptoms at diagnosis in asymptomatic (ASX)—incidental diagnosis—or symptomatic. Results. Of the 593 patients, 320 (53.9%) were ASX. In 71.8% of these, diagnosis was made by chest X-ray. Patients in the ASX group were older (), had a higher prevalence of previous malignancy (), presented as a solitary nodule more frequently (), and were more likely to have earlier-stage disease and smaller cancers (). A higher prevalence of incidental detection was observed in the last ten years (). Overall 5-year survival was higher for ASX (). Median survival times in pathological stages IIIB-IV were not significantly different. Conclusion. Incidental finding of NSCLC is not uncommon even among nonsmokers. It occurred frequently in smokers and in those with history of previous malignancy. Mortality of incidental diagnosis group was lower, but the better survival was related to the greater number of patients with earlier-stage disease. S. Quadrelli, G. Lyons, H. Colt, D. Chimondeguy, and A. Buero Copyright © 2015 S. Quadrelli et al. All rights reserved. Close Margins in Oral Cancers: Implication of Close Margin Status in Recurrence and Survival of pT1N0 and pT2N0 Oral Cancers Tue, 11 Nov 2014 11:54:24 +0000 http://www.hindawi.com/journals/ijso/2014/545372/ Introduction. Among all prognostic factors, “margin status” is the only factor under clinician’s control. Current guidelines describe histopathologic margin of >5 mm as “clear margin” and 1–5 mm as “close margin.” Ambiguous description of positive margin in the published data resulted in comparison of microscopically “involved margin” and “close margin” together with “clear margin” in many publications. Authors attempted to compare the outcome of close and clear margins of stage I and stage II squamous cell carcinoma of oral cavity to investigate the efficacy of description of margin status. Patients and Methods. Historical cohorts of patients treated between January 2010 and December 2011 at tertiary cancer hospital were investigated and filtered for stage I and stage II primary squamous cell carcinomas of oral cavity. Patients with margin status of tumor at margin or within 1mm from cut margin were excluded and analyzed in multivariate logistic regression model for locoregional recurrences and Cox regression for overall survival. Results. A total of 104 patients fulfilled the abovementioned criteria, of whom 36 were “clear margin” and 68 were “close margin” with median period of follow-up of 39 months. There was no significant difference in locoregional recurrence (P value: 0.0.810) and survival (P value: 0.0.851) among “close margin” and “clear margin” patients. Sandhya Gokavarapu, Ravi Chander, Nagendra Parvataneni, and Sreenivasa Puthamakula Copyright © 2014 Sandhya Gokavarapu et al. All rights reserved. Emergency Surgery for Metastatic Melanoma Tue, 28 Oct 2014 06:40:32 +0000 http://www.hindawi.com/journals/ijso/2014/987170/ Visceral metastases from malignant melanoma (stage M1c) confer a very poor prognosis, as documented on the most recent revised version of the TNM/AJCC staging system. Emergency surgery for intra-abdominal complications from the disease is rare. We report on our 5-year single institution experience with surgical management of metastatic melanoma to the viscera in the emergent setting. From 2009 to 2013, 14 patients with metastatic melanoma were admitted emergently due to an acute abdomen. Clinical manifestations encompassed intestinal obstruction and bleeding. Surgical procedures involved multiple enterectomies with primary anastomoses in 8 patients, and one patient underwent splenectomy, one adrenalectomy, one right colectomy, one gastric wedge resection, one gastrojejunal anastomosis, and one transanal debulking, respectively. The 30-day mortality was 7 percent. Median follow-up was 14 months. Median overall survival was 14 months. Median disease free survival was 7.5 months. One-year overall survival was 64.2 percent and 2-year overall survival was 14.2 percent. Emergency surgery for metastatic melanoma to the viscera is rare. Elective curative surgery combined with novel cytotoxic systemic therapies is under investigation in an attempt to grant survival benefit in melanoma patients with visceral disease. Dimitrios Mantas, Petros Tsaparas, Petros Charalampoudis, Helen Gogas, and Gregory Kouraklis Copyright © 2014 Dimitrios Mantas et al. All rights reserved. Evaluation of a New Modification of Pancreaticogastrostomy after Pancreaticoduodenectomy: Anastomosis of the Pancreatic Duct to the Gastric Mucosa with Invagination of the Pancreatic Remnant End into the Posterior Gastric Wall for Patients with Cancer Head of Pancreas and Periampullary Carcinoma in terms of Postoperative Pancreatic Fistula Formation Tue, 16 Sep 2014 00:00:00 +0000 http://www.hindawi.com/journals/ijso/2014/490386/ Background/Objectives. Postoperative pancreatic fistula (POPF) remains the main problem after pancreaticoduodenectomy and determines to a large extent the final outcome. We describe a new modification of pancreaticogastrostomy which combines duct to mucosa anastomosis with suturing the pancreatic capsule to posterior gastric wall and then invaginating the pancreatic remnant into the posterior gastric wall. This study was designed to assess the results of this new modification of pancreaticogastrostomy. Methods. The newly modified pancreaticogastrostomy was applied to 37 consecutive patients after pancreaticoduodenectomy for periampullary cancer (64.86%) or cancer head of the pancreas (35.14%). Eighteen patients (48.65%) had a soft pancreatic remnant, 13 patients (35.14%) had firm pancreatic remnant, and 6 patients (16.22%) had intermediate texture of pancreatic remnant. Rate of mortality, early postoperative complications, and hospital stay were also reported. Results. Operative mortality was zero and morbidity was 29.73%. Only three patients (8.11%) developed pancreatic leaks; they were treated conservatively. Eight patients (16.1%) had delayed gastric emptying, one patient (2.70%) had minor hemorrhage, one patient (2.70%) had biliary leak, and four patients (10.81%) had superficial wound infection. Conclusions. The new modified pancreatogastrostomy seems safe and reliable with low rate of POPF. However, further prospective controlled trials are essential to support these results. Mohamed Mazloum Osman and Walid Abd El Maksoud Copyright © 2014 Mohamed Mazloum Osman and Walid Abd El Maksoud. All rights reserved. Minimally Invasive Esophagectomy for Esophageal Cancer: The First Experience from Pakistan Sun, 20 Jul 2014 09:10:51 +0000 http://www.hindawi.com/journals/ijso/2014/864705/ Background. Two common procedures for esophageal resection are Ivor Lewis esophagectomy and transhiatal esophagectomy. Both procedures have high morbidity rates of 20–46%. Minimally invasive esophagectomy has been introduced to decrease morbidity. We report initial experience of MIE to determine the morbidity and mortality associated with this procedure during learning phase. Material and Methods. Patients undergoing MIE at our institute from January 2011 to May 2013 were reviewed. Record was kept for any morbidity and mortality. Descriptive statistics were presented as frequencies and continuous variables were presented as median. Survival analysis was performed using Kaplan Meier curves. Results. We performed 51 minimally invasive esophagectomies. Perioperative morbidity was in 16 (31.37%) patients. There were 3 (5.88%) anastomotic leaks. We encountered 1 respiratory complication. Reexploration was required in 3 (5.88%) patients. Median operative time was 375 minutes. Median hospital stay was 10 days. The most frequent long-term morbidity was anastomotic narrowing observed in 5 (9.88%) patients. There were no perioperative mortalities. Our mean overall survival was 37.66 months (95% confidence interval 33.75 to 41.56 months). Mean disease-free survival was 24.43 months (95% CI 21.26 to 27.60 months). Conclusion. Minimally invasive esophagectomy, when performed in the learning phase, has acceptable morbidity and mortality. Farrukh Hassan Rizvi, Syed Shahrukh Hassan Rizvi, Aamir Ali Syed, Shahid Khattak, and Ali Raza Khan Copyright © 2014 Farrukh Hassan Rizvi et al. All rights reserved. Prognostic Factors and Survival in Patients Treated Surgically for Recurrent Metastatic Uterine Leiomyosarcoma Sun, 22 Jun 2014 07:37:14 +0000 http://www.hindawi.com/journals/ijso/2014/919323/ Background. Uterine leiomyosarcoma (LMS) is a rare diagnosis, which is seldom cured when it recurs with metastatic disease. We evaluated patients who present with first time recurrence treated surgically to determine prognostic factors associated with long-term survival. Methods. Over a 16-year period, 41 patients were operated on for recurrent uterine sarcoma. Data examined included patient age, date of initial diagnosis, tumor histology, grade at the initial diagnosis, cytopathology changes in tumor activity from the initial diagnosis, residual tumor after all operations, use of adjuvant therapy, dates and sites of all recurrences, and disease status at last followup. Results. 24 patients were operated for first recurrence of metastatic uterine LMS. Complete tumor resection with histologic negative margins was achieved in 16 (67%) patients. Overall survival was significantly affected by the FIGO stage at the time of the initial diagnosis, the ability to obtain complete tumor resection at the time of surgery for first time recurrent disease, single tumor recurrence, and recurrence greater than 12 months from the time of the initial diagnosis. Median disease-free survival was 14 months and overall survival was 27 months. Conclusion. Our findings suggest that stage 1 at the time of initial diagnosis, recurrence greater than 12 months, isolated tumor recurrence, and the ability to remove ability to perform complete tumor resection at the time of the first recurrence can afford improved survival in selected patientsat the time of the first recurrence can afford improved survival in selected patients. Han L. T. Hoang, Kelsey Ensor, Gerald Rosen, H. Leon Pachter, and Joseph S. Raccuia Copyright © 2014 Han L. T. Hoang et al. All rights reserved. Cytoreductive Surgery and HIPEC for Peritoneal Carcinomatosis in the Elderly Wed, 16 Apr 2014 08:33:58 +0000 http://www.hindawi.com/journals/ijso/2014/987475/ Background. The combined treatment of peritoneal carcinomatosis with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a rigorous surgical treatment, most suitable for young and good performance status patients. We evaluated the outcomes of elderly patients undergoing CRS and HIPEC for peritoneal carcinomatosis with careful perioperative care. Methods. All consecutive patients 70 years of age or older who were treated for peritoneal carcinomatosis over the past five years were included. Primary outcomes were perioperative morbidity and mortality. Secondary outcomes were disease-free survival and overall survival. Results. From a pool of 100 patients, with a diagnosis of PC who underwent CRS and HIPEC in our center, we have included 30 patients at an age of 70 years or older and the results were compared to the patients younger than 70 years. The total morbidity rate was 50% versus 41.5% in the group younger than 70 years (NSS). The mortality rate was 3.3% in the elderly group versus 1.43% in the younger group (NSS). Median overall survival was 30 months in the older group versus 38 months in the younger group. Conclusion. Cytoreductive surgery and HIPEC for peritoneal carcinomatosis may be safely performed with acceptable morbidity in selected elderly patients. J. D. Spiliotis, E. Halkia, V. A. Boumis, D. T. Vassiliadou, A. Pagoulatou, and E. Efstathiou Copyright © 2014 J. D. Spiliotis et al. All rights reserved. Incisional Surgical Site Infection after Elective Open Surgery for Colorectal Cancer Thu, 27 Mar 2014 09:03:18 +0000 http://www.hindawi.com/journals/ijso/2014/419712/ Background. The purpose of this study was to clarify the incidence and risk factors for incisional surgical site infections (SSI) in patients undergoing elective open surgery for colorectal cancer. Methods. We conducted prospective surveillance of incisional SSI after elective colorectal resections performed by a single surgeon for a 1-year period. Variables associated with infection, as identified in the literature, were collected and statistically analyzed for their association with incisional SSI development. Results. A total of 224 patients were identified for evaluation. The mean patient age was 67 years, and 120 (55%) were male. Thirty-three (14.7%) patients were diagnosed with incisional SSI. Multivariate analysis suggested that incisional SSI was independently associated with TNM stages III and IV (odds ratio [OR], 2.4) and intraoperative hypotension (OR, 3.4). Conclusions. The incidence of incisional SSI in our cohort was well within values generally reported in the literature. Our data suggest the importance of the maintenance of intraoperative normotension to reduce the development of incisional SSI. Kosuke Ishikawa, Takaya Kusumi, Masao Hosokawa, Yasunori Nishida, Sosuke Sumikawa, and Hiroshi Furukawa Copyright © 2014 Kosuke Ishikawa et al. All rights reserved. The Aetiology of Delay to Commencement of Adjuvant Chemotherapy following Colorectal Resection Mon, 17 Mar 2014 07:07:58 +0000 http://www.hindawi.com/journals/ijso/2014/670212/ Purpose. Timely administration of adjuvant chemotherapy following colorectal resection is associated with improved outcome. We aim to assess the factors which are associated with delay to adjuvant chemotherapy in patients who underwent colorectal resection as part of an enhanced recovery protocol. Method. A univariate and multivariate analysis of patient data collected as part of a prospectively maintained database of colorectal cancer patients between 2007 and 2012. Results. 166 patients underwent colorectal resection followed by adjuvant chemotherapy. Median postoperative hospital stay was 6 days, and time to commencement of adjuvant chemotherapy was 50 days. Longer inpatient stay correlated with increased time to adjuvant chemotherapy (). Factors found to be independently associated with duration of hospital stay and time to commencement of adjuvant chemotherapy included stoma formation (), anastaomotic leak (), and preoperative albumin (). The use of laparoscopic surgery was associated with shorter time to adjuvant chemotherapy but did not reach significance (). Conclusion. A number of independent variables associated with delay to adjuvant therapy previously not described have been identified. Further work may be required to elucidate the effect that these variables have on long-term outcome. G. S. Simpson, R. Smith, P. Sutton, A. Shekouh, C. McFaul, M. Johnson, and D. Vimalachandran Copyright © 2014 G. S. Simpson et al. All rights reserved. Regional Failures after Selective Neck Dissection in Previously Untreated Squamous Cell Carcinoma of Oral Cavity Tue, 11 Mar 2014 13:13:44 +0000 http://www.hindawi.com/journals/ijso/2014/205715/ Aim. To share experience with regional failures after selective neck dissection in both node negative and positive previously untreated patients diagnosed with squamous cell carcinoma of the oral cavity. Patients and Methods. Data of 219 patients who underwent SND at Shaukat Khanum Cancer Hospital from 2003 to 2010 were retrospectively reviewed. Patient characteristics, treatment modalities, and regional failures were assessed. Expected 5-year regional control was calculated and prognostic factors were determined. Results. Median follow-up was 29 (9–109) months. Common sites were anterior tongue in 159 and buccal mucosa in 22 patients. Pathological nodal stage was N0 in 114, N1 in 32, N2b in 67, and N2c in 5 patients. Fourteen (6%) patients failed in clinically node negative neck while 8 (4%) failed in clinically node positive patients. Out of 22 total regional failures, primary tumor origin was from tongue in 16 (73%) patients. Expected 5-year regional control was 95% and 81% for N0 and N+ disease, respectively (). Only 13% patients with well differentiated, T1 tumors in cN0 neck were pathologically node positive. Conclusions. Selective neck dissection yields acceptable results for regional management of oral squamous cell carcinoma. Wait and see policy may be effective in a selected subgroup of patients. Hassan Iqbal, Abu Bakar Hafeez Bhatti, Raza Hussain, and Arif Jamshed Copyright © 2014 Hassan Iqbal et al. All rights reserved. The Treatment of Peritoneal Carcinomatosis in Advanced Gastric Cancer: State of the Art Mon, 17 Feb 2014 16:18:07 +0000 http://www.hindawi.com/journals/ijso/2014/912418/ Gastric cancer (GC) is the fourth most common cancer and the second leading cause of cancer death in the world; 53–60% of patients show disease progression and die of peritoneal carcinomatosis (PC). PC of gastric origin has an extremely inauspicious prognosis with a median survival estimate at 1–3 months. Different studies presented contrasting data about survival rates; however, all agreed with the necessity of a complete cytoreduction to improve survival. Hyperthermic intraperitoneal chemotherapy (HIPEC) has an adjuvant role in preventing peritoneal recurrences. A multidisciplinary approach should be empowered: the association of neoadjuvant intraperitoneal and systemic chemotherapy (NIPS), cytoreductive surgery (CRS), HIPEC, and early postoperative intraperitoneal chemotherapy (EPIC) could increase the rate of completeness of cytoreduction (CC) and consequently survival rates, especially in patients with Peritoneal Cancer Index (PCI) ≤6. Neoadjuvant chemotherapy may improve survival also in PC from GC and adjuvant chemotherapy could prevent recurrence. In the last decade an interesting new drug, called Catumaxomab, has been developed in Germany. Two studies showed that this drug seems to improve progression-free survival in patients with GC; however, final results for both studies have still to be published. Giulia Montori, Federico Coccolini, Marco Ceresoli, Fausto Catena, Nicola Colaianni, Eugenio Poletti, and Luca Ansaloni Copyright © 2014 Giulia Montori et al. All rights reserved.